Please complete the form using black ball point pen and BLOCK letters and numbers only.Submission needs to be attached with relevant supporting documents.

Sila lengkapkan borang dengan pena mata bulat dan huruf BESAR dan nombor sahaja.Permohanan haruslah disertakan dengan dokumen sokongan yang relevan.

A. JENIS PERMOHONANTYPE OF APPLICATION

B. JENIS SYARIKATTYPE OF COMPANY

C. COMPANY / INDIVIDUAL PARTICULARS

SMARTPAY APPLICATION FORM / BORANG PERMOHONAN SMARTPAY PETRONAS Customer Experience CentreSuite A-1-1, Hampshire Place Office, 157 HampshireNo.1, Jalan Mayang Sari50450 Kuala Lumpur

/ Pusat Pengalaman Pelanggan PETRONAS

TEL 1-300-88-8282 FAX 1-300-22-3333

(If subsidy, please specify subsidy number)(Jika subsidi, sila isikan nombor subsidi) (If yes, please specify the account number)(Jika ya, sila isikan nombor akaun)

Berhad Berhad

- Annual Report- Original letter from MDTCC* for Subsidy Application

- Laporan Tahunan- Surat Kelulusan dari KPDNKK* untuk Permohonan Subsidi

- Company Registration Document (Form 9 or 13, 24 & 49)- Memorandum & Articles of Association - Latest Audited Account- Latest 2 month Bank Statements- Original Letter from MDTCC* for Subsidy Application

- Dokumen Pendaftaran Perniagaan (Borang 9 atau 13, 24 & 49)- Memorandum & Perkara-perkara Persatuan Syarikat- Akaun Beraudit terkini- 2 bulan Penyata Bank terkini- Surat Kelulusan Asal dari KPDNKK* untuk Permohonan Subsidi

- Company Registration Document - Copy of Identity Card - Latest 2 years Profit & Loss Statements- Latest 2 month Bank Statements- Original Letter from MDTCC* for Subsidy Application

- Dokumen Pendaftaran Perniagaan - Salinan Kad Pengenalan- 2 tahun Penyata Keuntungan & Kerugian terkini- 2 bulan Penyata Bank terkini- Surat Kelulusan Asal dari KPDNKK* untuk Permohonan Subsidi

- Copy of Identity Card - Latest 2 month Bank Statements- Original Letter from MDTCC* for Subsidy Application

- Salinan Kad Pengenalan- 2 bulan Penyata Bank terkini- Surat Kelulusan Asal dari KPDNKK* untuk Permohonan Subsidi

- Official Request Letter

- Surat Permohonan Rasmi

BERHADBERHAD

SENDIRIAN BERHADSENDIRIAN BERHAD

SOLE PROPRIETOR / PARTNERSHIPPEMILIKAN TUNGGAL / PERKONGSIAN

INDIVIDUALINDIVIDU

GOVERNMENTJABATAN KERAJAAN

SmartpaySmartPay

Diesel SubsidySubsidi Diesel

Petrol SubsidySubsidi Petrol

Subsidy No. No. Subsidi

Existing PETRONAS SmartPay Account HolderPemegang Akaun PETRONAS SmartPay?

Account No. No. AkaunYesYa

NoTidak

Sdn BhdSdn Bhd

Sole ProprietorPemilikan Tunggal

PartnershipPerkongsian

IndividualIndividu

GovernmentJabatan Kerajaan

SUPPORTING DOCUMENTS FOR EACH CATEGORYDOKUMEN SOKONGAN UNTUK SETIAP KATEGORI

MAKLUMAT SYARIKAT / INDIVIDU COMPANY / INDIVIDUAL NAME NAMA SYARIKAT / INDIVIDU

COMPANY / INDIVIDUAL NAME TO APPEAR ON THE CARD (MAX. 25 Characters including space(s))NAMA SYARIKAT / INDIVIDU UNTUK TERTERA PADA KAD (Maks. 25 huruf termasuk jarak)

ADDRESS (P.O Box Address NOT Acceptable) ALAMAT (Alamat Peti Surat Pejabat Pos TIDAK diterima)

E-MAIL ADDRESS ALAMAT E-MEL

POSTCODE POSKOD

TELEPHONE NO. NO. TELEFON FAX NO. NO. FAKS

CITY BANDAR STATE NEGERI

*Ministry of Domestic Trade, Co-operatives And Consumerism / *Kementerian Perdagangan Dalam Negeri, Koperasi Dan Kepenggunaan

MOBILE NO. NO. TELEFON BIMBIT PREFERRED LANGUAGE (Please tick (√ ) one)English

BAHASA PILIHAN (Sila tanda ( √ ) satu)

Bahasa InggerisBahasa Malaysia

WEBSITE LAMAN SESAWANG

CONTACT PERSON NAME NAMA PEGAWAI UNTUK DIHUBUNGI

AUTHORISED SIGNATORY NAME NAMA PENANDATANGAN YANG SAH

COMPANY REG. DATE TARIKH PENDAFTARAN SYARIKAT

IDENTITY CARD NO. NO. KAD PENGENALANCOMPANY REG. NO. NO. PENDAFTARAN SYARIKAT

(yyyy-mm-dd) (tttt-bb-hh)

I/We confirm that all information contained herein are true and complete and authorise PETRONAS Dagangan Berhad to verify from whatever sources PETRONAS Dagangan Berhad may consider appropriate. I/We hereby acknowlegde that the Card may only be used subject to terms and conditions of the PETRONAS SmartPay Fleetcard Cardholder agreement.

Authorised SignatoryTandatangan Pengesahan

Name:Nama:

Date:Tarikh:

Identity Card No.:No. Kad Pengenalan:

Official Company StampCop Rasmi Syarikat

Approval: Kelulusan:

FORM/SP/A/02/01/201104

Designation:Jawatan:

F.

COST CENTRE NAME (Optional)NAMA PUSAT TANGGUNGJAWAB (Tidak Wajib)

COST CENTRE LIMIT(Optional)HAD PUSAT TANGGUNGJAWAB (Tidak Wajib)

(RM)

Stan

dalo

nePe

rsen

diria

nDr

iver

Pem

andu

No.

No. Ve

hicl

eKe

nder

aan

Subs

idy

Subs

idi

Flee

t Man

ager

Peng

urus

Ken

dera

an

Card Type (Please tick (√) one)Jenis Kad (Sila tanda (√) satu)

Vehicle Registration No.

No.Pendaftaran Kenderaan

Name To Appear On Card(Max. 25 characters including space (s))

Nama Yang Akan Tertera Pada Kad(Maks. 25 huruf termasuk jarak)

Dies

el

Lubr

ican

tPe

linci

r

Petr

ol R

ON

95

Petr

ol R

ON

97

Keda

i Mes

ra

1

2

3

4

5

Single Transaction

LimitHad SatuTransaksi

Daily Card LimitHad Harian Kad

Purchase Limit (To nearest RM value)Had Pembelian (RM) (Kepada nilai RM terdekat)

Monthly Card LimitHad Bulanan Kad

Count Limit (Optional)Had Kiraan (Tidak Wajib)

Daily Transaction

LimitHad

TransaksiHarian

MonthlyTransaction

LimitHad

TransaksiBulanan

D. PUSAT TANGGUNGJAWAB / MAKLUMAT KADCOST CENTRE / CARD INFORMATION (For multiple cost centre, please fill up separate form) (Sila isikan di dalam borang berasingan jika pusat tanggungjawab lebih dari satu)

E.E. PENGESAHAN DAN SOKONGANDECLARATION AND ENDORSEMENT UNTUK KEGUNAAN PETRONASFOR PETRONAS USE

F.ACCOUNT AKAUN

:

:

:

:

:

MONTLY QUOTA (litres)KUOTA BULANAN (liter)

PRE-PAID POST-PAID

START DATE QUOTA (yyyy-mm-dd)TARIKH MULA KUOTA (tttt-bb-hh)

END DATE QUOTA (yyyy-mm-dd)TARIKH TAMAT KUOTA (tttt-bb-hh)

MDTCC REFERENCE NO.NO. RUJUKAN KPDNKK

SALES REPRESENTATIVEWAKIL PENJUALBILLING CYCLETARIKH BIL

COLLECTORPEMUNGUTPRODUCT CODEKOD PRODUK

INDUSTRY CODEKOD INDUSTRI

CUSTOMER CLASSKELAS PELANGGAN

SALES REGIONWILAYAH PENJUALAN

CLAIM TYPEJENIS TUNTUTAN

STATUSSTATUS

APPROVEDLULUS

PENDINGBELUM DILULUSKAN

:

:

:

:

:

:

:

:

:

By submitting this application and/or continuing to transact with Petronas Dagangan Berhad (“PDB”), you are deemed to have agreed and consented to the collection, processing, use, disclosure and retention by PDB of your personal data in the manner as set out in the Personal Data Notice given pursuant to Section 7 of the Personal Data Protection Act 2010, which can be viewed at www.mymesra.com.my/pdpa

Product Category (Can tick (√) more than one)

Kategori Produk (Boleh tanda (√) lebih daripada satu)

UNTUK KEGUNAAN PETRONAS - SambunganFOR PETRONAS USE - Continue

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